<status value="draft"/> <experimental value="false"/> <date value="2026-06-03T16:00:06+02:00"/> <publisher value="IKNL"/> <description value="This form was developed to clearly document agreements resulting from the advance care planning (ACP) process. It is NOT a checklist. It can only be completed by a healthcare provider after a professional and nuanced conversation. For advice on conducting these conversations, please refer to the guideline for advance care planning in the palliative phase and Palliaweb, see https://palliaweb.nl/zorgpraktijk/proactieve-zorgplanning. Enter 'unknown' if a topic is not discussed or if the patient does not (yet) have an opinion.When transferring to a long-term care setting, consider adding conversation records about advance care planning (ACP) to the transfer documents. "/> <purpose value="This form was developed to clearly document agreements resulting from the advance care planning (ACP) process."/> <jurisdiction> <coding> <system value="http://unstats.un.org/unsd/methods/m49/m49.htm"/> <code value="001"/> </coding> </jurisdiction> <contact> <telecom> <system value="url"/> <value value="https://www.iknl.nl"/> </telecom> </contact> <copyright value="This form is subject to copyright, user rights and a disclaimer, as specified for all IKNL information standards. 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<initialCoding> <system value="http://snomed.info/sct"/> <code value="40617009"/> <display value="Kunstmatige beademing (verrichting)"/> </initialCoding> </item> <item> <linkId value="588"/> <text value="BehandelingToegestaan"/> <type value="choice"/> <required value="false"/> <repeats value="false"/> <option> <valueCoding> <system value="urn:oid:2.16.840.1.113883.2.4.3.11.60.40.4"/> <code value="JA"/> <display value="Ja"/> </valueCoding> </option> <option> <valueCoding> <system value="urn:oid:2.16.840.1.113883.2.4.3.11.60.40.4"/> <code value="JA_MAAR"/> <display value="Ja, maar met beperkingen"/> </valueCoding> </option> <option> <valueCoding> <system value="urn:oid:2.16.840.1.113883.2.4.3.11.60.40.4"/> <code value="NEE"/> <display value="Nee"/> </valueCoding> </option> <option> <valueCoding> <system value="http://terminology.hl7.org/CodeSystem/v3-NullFlavor"/> <code value="UNK"/> <display value="Onbekend"/> </valueCoding> </option> <item> <linkId value="123"/> <text value="Beperkingen"/> <type value="string"/> <enableWhen> <question value="588"/> <answerCoding> <system value="urn:oid:2.16.840.1.113883.2.4.3.11.60.40.4"/> <code value="JA_MAAR"/> </answerCoding> </enableWhen> <required value="false"/> <repeats value="false"/> </item> <item> <linkId value="92"/> <text value="Toelichting"/> <type value="string"/> <required value="false"/> <repeats value="false"/> </item> </item> </item> <item> <linkId value="796"/> <prefix value="c)"/> <text value="Opname op intensive care"/> <type value="group"/> <repeats value="false"/> <item> <linkId value="795"/> <text value="Behandeling"/> <type value="choice"/> <required value="false"/> <repeats value="false"/> <readOnly value="true"/> <option> <valueCoding> <system value="http://snomed.info/sct"/> <code value="305351004"/> <display value="Opname op intensive care (verrichting)"/> </valueCoding> </option> <initialCoding> <system value="http://snomed.info/sct"/> <code value="305351004"/> <display value="Opname op intensive care (verrichting)"/> </initialCoding> </item> <item> <linkId value="589"/> <text value="BehandelingToegestaan"/> <type value="choice"/> <required value="false"/> <repeats value="false"/> <option> <valueCoding> <system value="urn:oid:2.16.840.1.113883.2.4.3.11.60.40.4"/> <code value="JA"/> <display value="Ja"/> </valueCoding> </option> <option> <valueCoding> <system value="urn:oid:2.16.840.1.113883.2.4.3.11.60.40.4"/> <code value="JA_MAAR"/> <display value="Ja, maar met beperkingen"/> </valueCoding> </option> <option> <valueCoding> <system value="urn:oid:2.16.840.1.113883.2.4.3.11.60.40.4"/> <code value="NEE"/> <display value="Nee"/> </valueCoding> </option> <option> <valueCoding> <system value="http://terminology.hl7.org/CodeSystem/v3-NullFlavor"/> <code value="UNK"/> <display value="Onbekend"/> </valueCoding> </option> <item> <linkId value="124"/> <text value="Beperkingen"/> <type value="string"/> <enableWhen> <question value="589"/> <answerCoding> <system value="urn:oid:2.16.840.1.113883.2.4.3.11.60.40.4"/> <code value="JA_MAAR"/> </answerCoding> </enableWhen> <required value="false"/> <repeats value="false"/> </item> <item> <linkId value="88"/> <text value="Toelichting"/> <type value="string"/> <required value="false"/> <repeats value="false"/> </item> </item> </item> <item> <linkId value="798"/> <prefix value="d)"/> <text value="Opname in ziekenhuis"/> <type value="group"/> <repeats value="false"/> <item> <linkId value="799"/> <text value="Behandeling"/> <type value="choice"/> <required value="false"/> <repeats value="false"/> <readOnly value="true"/> <option> <valueCoding> <system value="http://snomed.info/sct"/> <code value="32485007"/> <display value="Opname in ziekenhuis (verrichting)"/> </valueCoding> </option> <initialCoding> <system value="http://snomed.info/sct"/> <code value="32485007"/> <display value="Opname in ziekenhuis (verrichting)"/> </initialCoding> </item> <item> <linkId value="590"/> <text value="BehandelingToegestaan"/> <type value="choice"/> <required value="false"/> <repeats value="false"/> <option> <valueCoding> <system value="urn:oid:2.16.840.1.113883.2.4.3.11.60.40.4"/> <code value="JA"/> <display value="Ja"/> </valueCoding> </option> <option> <valueCoding> <system value="urn:oid:2.16.840.1.113883.2.4.3.11.60.40.4"/> <code value="JA_MAAR"/> <display value="Ja, maar met beperkingen"/> </valueCoding> </option> <option> <valueCoding> <system value="urn:oid:2.16.840.1.113883.2.4.3.11.60.40.4"/> <code value="NEE"/> <display value="Nee"/> </valueCoding> </option> <option> <valueCoding> <system value="http://terminology.hl7.org/CodeSystem/v3-NullFlavor"/> <code value="UNK"/> <display value="Onbekend"/> </valueCoding> </option> <item> <linkId value="125"/> <text value="Beperkingen"/> <type value="string"/> <enableWhen> <question value="590"/> <answerCoding> <system value="urn:oid:2.16.840.1.113883.2.4.3.11.60.40.4"/> <code value="JA_MAAR"/> </answerCoding> </enableWhen> <required value="false"/> <repeats value="false"/> </item> <item> <linkId value="94"/> <text value="Toelichting"/> <type value="string"/> <required value="false"/> <repeats value="false"/> </item> </item> </item> <item> <linkId value="800"/> <prefix value="e)"/> <text value="Behandeling met antibiotica"/> <type value="group"/> <repeats value="false"/> <item> <linkId value="801"/> <text value="Behandeling"/> <type value="choice"/> <required value="false"/> <repeats value="false"/> <readOnly value="true"/> <option> <valueCoding> <system value="http://snomed.info/sct"/> <code value="281789004"/> <display value="Antibiotische therapie (verrichting)"/> </valueCoding> </option> <initialCoding> <system value="http://snomed.info/sct"/> <code value="281789004"/> <display value="Antibiotische therapie (verrichting)"/> </initialCoding> </item> <item> <linkId value="591"/> <text value="BehandelingToegestaan"/> <type value="choice"/> <required value="false"/> <repeats value="false"/> <option> <valueCoding> <system value="urn:oid:2.16.840.1.113883.2.4.3.11.60.40.4"/> <code value="JA"/> <display value="Ja"/> </valueCoding> </option> <option> <valueCoding> <system value="urn:oid:2.16.840.1.113883.2.4.3.11.60.40.4"/> <code value="JA_MAAR"/> <display value="Ja, maar met beperkingen"/> </valueCoding> </option> <option> <valueCoding> <system value="urn:oid:2.16.840.1.113883.2.4.3.11.60.40.4"/> <code value="NEE"/> <display value="Nee"/> </valueCoding> </option> <option> <valueCoding> <system value="http://terminology.hl7.org/CodeSystem/v3-NullFlavor"/> <code value="UNK"/> <display value="Onbekend"/> </valueCoding> </option> <item> <linkId value="126"/> <text value="Beperkingen"/> <type value="string"/> <enableWhen> <question value="591"/> <answerCoding> <system value="urn:oid:2.16.840.1.113883.2.4.3.11.60.40.4"/> <code value="JA_MAAR"/> </answerCoding> </enableWhen> <required value="false"/> <repeats value="false"/> </item> <item> <linkId value="96"/> <text value="Toelichting"/> <type value="string"/> <required value="false"/> <repeats value="false"/> </item> </item> </item> <item> <linkId value="802"/> <prefix value="f)"/> <text value="Toediening van een bloedproduct"/> <type value="group"/> <repeats value="false"/> <item> <linkId value="803"/> <text value="Behandeling"/> <type value="choice"/> <required value="false"/> <repeats value="false"/> <readOnly value="true"/> <option> <valueCoding> <system value="http://snomed.info/sct"/> <code value="116762002"/> <display value="Toediening van bloedproduct (verrichting)"/> </valueCoding> </option> <initialCoding> <system value="http://snomed.info/sct"/> <code value="116762002"/> <display value="Toediening van bloedproduct (verrichting)"/> </initialCoding> </item> <item> <linkId value="592"/> <text value="BehandelingToegestaan"/> <type value="choice"/> <required value="false"/> <repeats value="false"/> <option> <valueCoding> <system value="urn:oid:2.16.840.1.113883.2.4.3.11.60.40.4"/> <code value="JA"/> <display value="Ja"/> </valueCoding> </option> <option> <valueCoding> <system value="urn:oid:2.16.840.1.113883.2.4.3.11.60.40.4"/> <code value="JA_MAAR"/> <display value="Ja, maar met beperkingen"/> </valueCoding> </option> <option> <valueCoding> <system value="urn:oid:2.16.840.1.113883.2.4.3.11.60.40.4"/> <code value="NEE"/> <display value="Nee"/> </valueCoding> </option> <option> <valueCoding> <system value="http://terminology.hl7.org/CodeSystem/v3-NullFlavor"/> <code value="UNK"/> <display value="Onbekend"/> </valueCoding> </option> <item> <linkId value="127"/> <text value="Beperkingen"/> <type value="string"/> <enableWhen> <question value="592"/> <answerCoding> <system value="urn:oid:2.16.840.1.113883.2.4.3.11.60.40.4"/> <code value="JA_MAAR"/> </answerCoding> </enableWhen> <required value="false"/> <repeats value="false"/> </item> <item> <linkId value="98"/> <text value="Toelichting"/> <type value="string"/> <required value="false"/> <repeats value="false"/> </item> </item> </item> <item> <linkId value="804"/> <prefix value="g)"/> <text value="Overige behandelgrenzen"/> <type value="group"/> <repeats value="false"/> <item> <linkId value="805"/> <text value="Behandeling"/> <type value="choice"/> <required value="false"/> <repeats value="false"/> <readOnly value="true"/> <option> <valueCoding> <system value="http://terminology.hl7.org/CodeSystem/v3-NullFlavor"/> <code value="OTH"/> <display value="Overige behandelingen"/> </valueCoding> </option> <initialCoding> <system value="http://terminology.hl7.org/CodeSystem/v3-NullFlavor"/> <code value="OTH"/> <display value="Overige behandelingen"/> </initialCoding> <item> <linkId value="1033"/> <text value="Overige behandelingen, namelijk:"/> <type value="string"/> <required value="false"/> <repeats value="false"/> </item> </item> <item> <linkId value="593"/> <text value="BehandelingToegestaan"/> <type value="choice"/> <required value="false"/> <repeats value="false"/> <option> <valueCoding> <system value="urn:oid:2.16.840.1.113883.2.4.3.11.60.40.4"/> <code value="JA"/> <display value="Ja"/> </valueCoding> </option> <option> <valueCoding> <system value="urn:oid:2.16.840.1.113883.2.4.3.11.60.40.4"/> <code value="NEE"/> <display value="Nee"/> </valueCoding> </option> <option> <valueCoding> <system value="http://terminology.hl7.org/CodeSystem/v3-NullFlavor"/> <code value="UNK"/> <display value="Onbekend"/> </valueCoding> </option> <item> <linkId value="100"/> <text value="Toelichting"/> <type value="string"/> <required value="false"/> <repeats value="false"/> </item> </item> </item> <item> <linkId value="249"/> <prefix value="h)"/> <text value="Heeft de patiënt een ICD?"/> <type value="choice"/> <required value="false"/> <repeats value="false"/> <options> <reference value="https://api.iknl.nl/docs/pzp/stu3/ValueSet/ACP-YesNoUnknownVS|1.0.0-rc3"/> </options> <item> <linkId value="600"/> <text value="ProductType van ICD"/> <type value="choice"/> <enableWhen> <question value="249"/> <answerCoding> <system value="http://snomed.info/sct"/> <code value="373066001"/> </answerCoding> </enableWhen> <required value="false"/> <repeats value="false"/> <options> <reference value="https://api.iknl.nl/docs/pzp/stu3/ValueSet/ACP-MedicalDeviceProductType-ICDVS|1.0.0-rc3"/> </options> </item> <item> <linkId value="599"/> <text value="Toelichting"/> <type value="string"/> <enableWhen> <question value="249"/> <answerCoding> <system value="http://snomed.info/sct"/> <code value="373066001"/> </answerCoding> </enableWhen> <required value="false"/> <repeats value="false"/> </item> </item> <item> <linkId value="808"/> <prefix value="i)"/> <text value="Is er een afspraak over het moment van uitzetten ICD?"/> <type value="group"/> <enableWhen> <question value="249"/> <answerCoding> <system value="http://snomed.info/sct"/> <code value="373066001"/> </answerCoding> </enableWhen> <repeats value="false"/> <item> <linkId value="809"/> <text value="Behandeling van uitzetten ICD"/> <type value="choice"/> <required value="false"/> <repeats value="false"/> <readOnly value="true"/> <option> <valueCoding> <system value="http://snomed.info/sct"/> <code value="400231000146108"/> <display value="uitzetten van cardioverter-defibrillator in laatste levensfase (verrichting)"/> </valueCoding> </option> <initialCoding> <system value="http://snomed.info/sct"/> <code value="400231000146108"/> <display value="uitzetten van cardioverter-defibrillator in laatste levensfase (verrichting)"/> </initialCoding> </item> <item> <linkId value="595"/> <text value="Afspraak uitzetten ICD (BehandelingToegestaan)"/> <type value="choice"/> <enableWhen> <question value="249"/> <answerCoding> <system value="http://snomed.info/sct"/> <code value="373066001"/> </answerCoding> </enableWhen> <required value="false"/> <repeats value="false"/> <option> <valueCoding> <system value="urn:oid:2.16.840.1.113883.2.4.3.11.60.40.4"/> <code value="JA"/> <display value="Ja"/> </valueCoding> </option> <option> <valueCoding> <system value="http://terminology.hl7.org/CodeSystem/v3-NullFlavor"/> <code value="ASKU"/> <display value="Nee, nog geen besluit genomen"/> </valueCoding> </option> <option> <valueCoding> <system value="http://terminology.hl7.org/CodeSystem/v3-NullFlavor"/> <code value="NASK"/> <display value="Niet besproken"/> </valueCoding> </option> <item> <linkId value="596"/> <text value="Toelichting gemaakte afspraken"/> <type value="string"/> <required value="false"/> <repeats value="false"/> </item> </item> </item> </item> <item> <linkId value="107"/> <prefix value="5"/> <text value="Behandelwensen"/> <type value="group"/> <repeats value="false"/> <item> <linkId value="810"/> <prefix value="a)"/> <text value="Wat zouden zorgverleners, volgens de patiënt, moeten weten om goede zorg te kunnen verlenen? Heeft deze patiënt specifieke wensen met betrekking tot zijn zorg? (incl. culturele/religieuze/sociale/spirituele aspecten)"/> <type value="group"/> <repeats value="false"/> <item> <linkId value="811"/> <text value="Wens en verwachting patient (MetingNaam)"/> <type value="choice"/> <required value="false"/> <repeats value="false"/> <readOnly value="true"/> <option> <valueCoding> <system value="http://snomed.info/sct"/> <code value="153851000146100"/> <display value="Wensen en verwachtingen met betrekking tot uitkomst van behandeling"/> </valueCoding> </option> <initialCoding> <system value="http://snomed.info/sct"/> <code value="153851000146100"/> <display value="Wensen en verwachtingen met betrekking tot uitkomst van behandeling"/> </initialCoding> </item> <item> <linkId value="382"/> <text value="Wens en verwachting patient (UitslagWaarde)"/> <type value="string"/> <required value="false"/> <repeats value="false"/> </item> <item> <linkId value="1034"/> <text value="Vaststellen wens en verwachting patiënt (Meetmethode)"/> <type value="choice"/> <required value="false"/> <repeats value="false"/> <readOnly value="true"/> <option> <valueCoding> <system value="http://snomed.info/sct"/> <code value="370819000"/> <display value="Vaststellen van persoonlijke waarden en wensen met betrekking tot zorg"/> </valueCoding> </option> <initialCoding> <system value="http://snomed.info/sct"/> <code value="370819000"/> <display value="Vaststellen van persoonlijke waarden en wensen met betrekking tot zorg"/> </initialCoding> </item> </item> <item> <linkId value="812"/> <prefix value="b)"/> <text value="Gewenste plek van overlijden"/> <type value="group"/> <repeats value="false"/> <item> <linkId value="1035"/> <text value="MetingNaam voor Gewenste plek van overlijden"/> <type value="choice"/> <required value="false"/> <repeats value="false"/> <readOnly value="true"/> <option> <valueCoding> <system value="http://snomed.info/sct"/> <code value="395091006"/> <display value="Voorkeur voor plaats van overlijden (waarneembare entiteit)"/> </valueCoding> </option> <initialCoding> <system value="http://snomed.info/sct"/> <code value="395091006"/> <display value="Voorkeur voor plaats van overlijden (waarneembare entiteit)"/> </initialCoding> </item> <item> <linkId value="604"/> <text value="Voorkeursplek (UitslagWaarde)"/> <type value="choice"/> <required value="false"/> <repeats value="false"/> <options> <reference value="https://api.iknl.nl/docs/pzp/stu3/ValueSet/ACP-PreferredPlaceOfDeathVS|1.0.0-rc3"/> </options> <item> <linkId value="110"/> <text value="Toelichting"/> <type value="string"/> <required value="false"/> <repeats value="false"/> </item> </item> <item> <linkId value="813"/> <prefix value="c)"/> <text value="Euthanasie standpunt"/> <type value="group"/> <repeats value="false"/> <item> <linkId value="816"/> <text value="MetingNaam voor Euthanasie standpunt"/> <type value="choice"/> <required value="false"/> <repeats value="false"/> <readOnly value="true"/> <option> <valueCoding> <system value="http://snomed.info/sct"/> <code value="340171000146104"/> <display value="Standpunt ten opzichte van euthanasie (waarneembare entiteit)"/> </valueCoding> </option> <initialCoding> <system value="http://snomed.info/sct"/> <code value="340171000146104"/> <display value="Standpunt ten opzichte van euthanasie (waarneembare entiteit)"/> </initialCoding> </item> <item> <linkId value="785"/> <text value="Standpunt (UitslagWaarde)"/> <type value="choice"/> <required value="false"/> <repeats value="false"/> <options> <reference value="https://api.iknl.nl/docs/pzp/stu3/ValueSet/ACP-PositionRegardingEuthanasiaVS|1.0.0-rc3"/> </options> <item> <linkId value="112"/> <text value="Toelichting"/> <type value="string"/> <required value="false"/> <repeats value="false"/> </item> </item> </item> <item> <linkId value="814"/> <prefix value="d)"/> <text value="Keuze orgaandonatie vastgelegd in donorregister?"/> <type value="group"/> <repeats value="false"/> <item> <linkId value="817"/> <text value="MetingNaam voor Keuze orgaandonatie vastgelegd in donorregister?"/> <type value="choice"/> <required value="false"/> <repeats value="false"/> <readOnly value="true"/> <option> <valueCoding> <system value="http://snomed.info/sct"/> <code value="570801000146104"/> <display value="Geregistreerd in orgaan donorregister (bevinding)"/> </valueCoding> </option> <initialCoding> <system value="http://snomed.info/sct"/> <code value="570801000146104"/> <display value="Geregistreerd in orgaan donorregister (bevinding)"/> </initialCoding> </item> <item> <linkId value="789"/> <text value="Keuze orgaandonatie in donorregister (UitslagWaarde)"/> <type value="choice"/> <required value="false"/> <repeats value="false"/> <options> <reference value="https://api.iknl.nl/docs/pzp/stu3/ValueSet/ACP-YesNoUnknownVS|1.0.0-rc3"/> </options> </item> <item> <linkId value="1036"/> <text value="Meetmethode voor Keuze orgaandonatie vastgelegd in donorregister?"/> <type value="choice"/> <required value="false"/> <repeats value="false"/> <readOnly value="true"/> <option> <valueCoding> <system value="http://snomed.info/sct"/> <code value="1156040003"/> <display value="Self reported (qualifier value)"/> </valueCoding> </option> <initialCoding> <system value="http://snomed.info/sct"/> <code value="1156040003"/> <display value="Self reported (qualifier value)"/> </initialCoding> </item> </item> </item> <item> <linkId value="598"/> <prefix value="6"/> <text value="Wat verder nog belangrijk is"/> <type value="group"/> <repeats value="false"/> <item> <linkId value="818"/> <text value="MetingNaam voor Wat verder nog belangrijk is"/> <type value="choice"/> <required value="false"/> <repeats value="false"/> <readOnly value="true"/> <option> <valueCoding> <system value="http://snomed.info/sct"/> <code value="247751003"/> <display value="Gevoel van zingeving (waarneembare entiteit)"/> </valueCoding> </option> <initialCoding> <system value="http://snomed.info/sct"/> <code value="247751003"/> <display value="Gevoel van zingeving (waarneembare entiteit)"/> </initialCoding> </item> <item> <linkId value="383"/> <text value="Wat verder nog belangrijk is (UitslagWaarde)"/> <type value="string"/> <required value="false"/> <repeats value="false"/> </item> </item> <item> <linkId value="115"/> <prefix value="7"/> <text value="Eerder vastgelegde behandelwensen"/> <type value="group"/> <repeats value="false"/> <item> <linkId value="253"/> <prefix value="a)"/> <text value="Heeft de patiënt eerder behandelafspraken vastgelegd?"/> <type value="choice"/> <required value="false"/> <repeats value="false"/> <options> <reference value="https://api.iknl.nl/docs/pzp/stu3/ValueSet/ACP-YesNoUnknownVS|1.0.0-rc3"/> </options> <item> <linkId value="254"/> <text value="Toelichting"/> <type value="string"/> <required value="false"/> <repeats value="false"/> </item> </item> <item> <linkId value="255"/> <prefix value="b)"/> <text value="Staan in eerder vastgelegde behandelafspraken andere wensen dan nu in deze verklaring?"/> <type value="choice"/> <enableWhen> <question value="253"/> <answerCoding> <system value="http://snomed.info/sct"/> <code value="373066001"/> </answerCoding> </enableWhen> <required value="false"/> <repeats value="false"/> <options> <reference value="https://api.iknl.nl/docs/pzp/stu3/ValueSet/ACP-YesNoUnknownVS|1.0.0-rc3"/> </options> </item> </item> <item> <linkId value="119"/> <prefix value="8"/> <text value="Informatie delen"/> <type value="group"/> <repeats value="false"/> <item> <linkId value="256"/> <prefix value="a)"/> <text value="Heeft u patient geïnformeerd over eigen verantwoordelijkheid om deze behandelafspraken met naasten te bespreken?"/> <type value="boolean"/> <required value="false"/> <repeats value="false"/> </item> <item> <linkId value="257"/> <prefix value="b)"/> <text value="Patiënt gaat akkoord met het delen van deze behandelafspraken met andere betrokken hulpverleners"/> <type value="choice"/> <required value="false"/> <repeats value="false"/> <option> <valueCoding> <system value="http://snomed.info/sct"/> <code value="441898007"/> <display value="Akkoord"/> </valueCoding> </option> <option> <valueCoding> <system value="http://terminology.hl7.org/CodeSystem/v3-NullFlavor"/> <code value="UNK"/> <display value="Nog onbekend"/> </valueCoding> </option> </item> </item> </item> </item> </Questionnaire>

Generated Narrative: Questionnaire ACP-zib2017

Tag:

Structure

LinkID	Text	Cardinality	Type	Description & Constraints
ACPzib2017	This form was developed to clearly document agreements resulting from the advance care planning (ACP) process. It is NOT a checklist. It can only be completed by a healthcare provider after a professional and nuanced conversation. For advice on conducting these conversations, please refer to the guideline for advance care planning in the palliative phase and Palliaweb, see https://palliaweb.nl/zorgpraktijk/proactieve-zorgplanning. Enter 'unknown' if a topic is not discussed or if the patient does not (yet) have an opinion.When transferring to a long-term care setting, consider adding conversation records about advance care planning (ACP) to the transfer documents.		Questionnaire	https://api.iknl.nl/docs/pzp/stu3/Questionnaire/ACP-zib2017#1.0.0-rc3
385	Datum van invullen	0..1	dateTime
7	Naam patiënt	0..1	group
386	Voornamen	0..1	string
387	Voorvoegsels	0..1	string
388	Achternaam	0..1	string
6	Geboortedatum patiënt	0..1	date
8	Gesprek gevoerd door:	0..1	group
16	Naam zorgverlener	0..1	group
389	Voornamen	0..1	string
390	Voorvoegsels	0..1	string
391	Achternaam	0..1	string
786	Functie (Specialisme)	0..1	choice	Value Set: ACP Health Professional Specialty
26	1. Wilsbekwaamheid & Wettelijke vertegenwoordiging	0..1	group
787	Is de patiënt op dit moment wilsbekwaam m.b.t. medische behandelbeslissingen?	0..1	boolean
788	Toelichting	0..1	string
29	Bij wilsonbekwaamheid m.b.t. medische behandelbeslissingen is/wordt de wettelijke vertegenwoordiger:	0..1	group
30	a). Naam wettelijk vertegenwoordiger	0..1	group
392	Voornamen	0..1	string
393	Voorvoegsels	0..1	string
394	Achternaam	0..1	string
39	b). Contactgegevens wettelijk vertegenwoordiger	0..1	group
40	Telefoonnummers	0..*	group
398	Telefoonnummer	0..1	string
399	TelecomType	0..1	choice	Options: 4 options
400	NummerSoort	0..1	choice	Options: 3 options
41	EmailAdressen	0..*	group
401	EmailAdres	0..1	string
402	EmailSoort	0..1	choice	Options: 2 options
410	c). Relatie tot patiënt (1)	0..*	choice	Options: 6 options Initial Value: Coding = unknown#24 "Wettelijke vertegenwoordiger"
411	Anders, namelijk:	0..1	string	Enable When: 410 = 9 (unknown#9)
51	c). Relatie tot patiënt (2)	0..1	choice	Options: 10 options
408	Anders, namelijk:	0..1	string	Enable When: 51 = other (NullFlavor#OTH)
52	d). Is de wettelijk vertegenwoordiger ook de eerste contactpersoon?	0..1	boolean
53	e). Naam eerste contactpersoon	0..1	group	Enable When: 52 = false
395	Voornamen	0..1	string
396	Voorvoegsels	0..1	string
397	Achternaam	0..1	string
61	f). Contactgegevens eerste contactpersoon	0..1	group	Enable When: 52 = false
62	Telefoonnummers	0..*	group
403	Telefoonnummer	0..1	string
404	TelecomType	0..1	choice	Options: 4 options
405	NummerSoort	0..1	choice	Options: 3 options
66	EmailAdressen	0..*	group
406	EmailAdres	0..1	string
407	EmailSoort	0..1	choice	Options: 2 options
819	Rol	0..1	choice	Options: 1 option Initial Value: Coding = unknown#1 "Eerste relatie/contactpersoon"
77	g). Relatie tot patiënt	0..1	choice	Enable When: 52 = false Options: 10 options
412	Anders, namelijk:	0..1	string	Enable When: 77 = other (NullFlavor#OTH)
78	2. Gesprek gevoerd in bijzijn van	0..1	group
82	Patiënt	0..1	choice	Options: 1 option
1038	Contactperso(o)n(en)	0..1	group
415	Rol	0..*	choice	Options: 4 options
414	Anders, namelijk:	0..1	string
80	Relatie tot patiënt	0..*	choice	Options: 10 options
413	Anders, namelijk:	0..1	string	Enable When: 80 = other (NullFlavor#OTH)
586	3. Belangrijkste overeengekomen doel van medisch beleid	0..1	group
790	MetingNaam voor Belangrijkste doel van behandeling	0..1	choice	Options: 1 option Initial Value: Coding = SNOMED CT#180771000146100 "Focus van behandeling (waarneembare entiteit)"
784	Doel (UitslagWaarde)	0..1	choice	Value Set: ACP Primary Agreed-upon Goal of Medical Policy Codes
83	4. Behandelgrenzen	0..1	group
792	a). Reanimatie	0..1	group
791	Behandeling	0..1	choice	Options: 1 option Initial Value: Coding = SNOMED CT#89666000 "Cardiopulmonale resuscitatie (verrichting)"
587	BehandelingToegestaan	0..1	choice	Options: 4 options
122	Beperkingen	0..1	string	Enable When: 587 = JA_MAAR (unknown#JA_MAAR)
86	Toelichting	0..1	string
793	b). Kunstmatige invasieve beademing	0..1	group
794	Behandeling	0..1	choice	Options: 1 option Initial Value: Coding = SNOMED CT#40617009 "Kunstmatige beademing (verrichting)"
588	BehandelingToegestaan	0..1	choice	Options: 4 options
123	Beperkingen	0..1	string	Enable When: 588 = JA_MAAR (unknown#JA_MAAR)
92	Toelichting	0..1	string
796	c). Opname op intensive care	0..1	group
795	Behandeling	0..1	choice	Options: 1 option Initial Value: Coding = SNOMED CT#305351004 "Opname op intensive care (verrichting)"
589	BehandelingToegestaan	0..1	choice	Options: 4 options
124	Beperkingen	0..1	string	Enable When: 589 = JA_MAAR (unknown#JA_MAAR)
88	Toelichting	0..1	string
798	d). Opname in ziekenhuis	0..1	group
799	Behandeling	0..1	choice	Options: 1 option Initial Value: Coding = SNOMED CT#32485007 "Opname in ziekenhuis (verrichting)"
590	BehandelingToegestaan	0..1	choice	Options: 4 options
125	Beperkingen	0..1	string	Enable When: 590 = JA_MAAR (unknown#JA_MAAR)
94	Toelichting	0..1	string
800	e). Behandeling met antibiotica	0..1	group
801	Behandeling	0..1	choice	Options: 1 option Initial Value: Coding = SNOMED CT#281789004 "Antibiotische therapie (verrichting)"
591	BehandelingToegestaan	0..1	choice	Options: 4 options
126	Beperkingen	0..1	string	Enable When: 591 = JA_MAAR (unknown#JA_MAAR)
96	Toelichting	0..1	string
802	f). Toediening van een bloedproduct	0..1	group
803	Behandeling	0..1	choice	Options: 1 option Initial Value: Coding = SNOMED CT#116762002 "Toediening van bloedproduct (verrichting)"
592	BehandelingToegestaan	0..1	choice	Options: 4 options
127	Beperkingen	0..1	string	Enable When: 592 = JA_MAAR (unknown#JA_MAAR)
98	Toelichting	0..1	string
804	g). Overige behandelgrenzen	0..1	group
805	Behandeling	0..1	choice	Options: 1 option Initial Value: Coding = NullFlavor#OTH "Overige behandelingen"
1033	Overige behandelingen, namelijk:	0..1	string
593	BehandelingToegestaan	0..1	choice	Options: 3 options
100	Toelichting	0..1	string
249	h). Heeft de patiënt een ICD?	0..1	choice	Value Set: ACP Yes, No, Unknown Codes
600	ProductType van ICD	0..1	choice	Enable When: 249 = Yes (qualifier value) (SNOMED CT#373066001) Value Set: ACP MedicalDevice ProductType ICD
599	Toelichting	0..1	string	Enable When: 249 = Yes (qualifier value) (SNOMED CT#373066001)
808	i). Is er een afspraak over het moment van uitzetten ICD?	0..1	group	Enable When: 249 = Yes (qualifier value) (SNOMED CT#373066001)
809	Behandeling van uitzetten ICD	0..1	choice	Options: 1 option Initial Value: Coding = SNOMED CT#400231000146108 "uitzetten van cardioverter-defibrillator in laatste levensfase (verrichting)"
595	Afspraak uitzetten ICD (BehandelingToegestaan)	0..1	choice	Enable When: 249 = Yes (qualifier value) (SNOMED CT#373066001) Options: 3 options
596	Toelichting gemaakte afspraken	0..1	string
107	5. Behandelwensen	0..1	group
810	a). Wat zouden zorgverleners, volgens de patiënt, moeten weten om goede zorg te kunnen verlenen? Heeft deze patiënt specifieke wensen met betrekking tot zijn zorg? (incl. culturele/religieuze/sociale/spirituele aspecten)	0..1	group
811	Wens en verwachting patient (MetingNaam)	0..1	choice	Options: 1 option Initial Value: Coding = SNOMED CT#153851000146100 "Wensen en verwachtingen met betrekking tot uitkomst van behandeling"
382	Wens en verwachting patient (UitslagWaarde)	0..1	string
1034	Vaststellen wens en verwachting patiënt (Meetmethode)	0..1	choice	Options: 1 option Initial Value: Coding = SNOMED CT#370819000 "Vaststellen van persoonlijke waarden en wensen met betrekking tot zorg"
812	b). Gewenste plek van overlijden	0..1	group
1035	MetingNaam voor Gewenste plek van overlijden	0..1	choice	Options: 1 option Initial Value: Coding = SNOMED CT#395091006 "Voorkeur voor plaats van overlijden (waarneembare entiteit)"
604	Voorkeursplek (UitslagWaarde)	0..1	choice	Value Set: ACP Preferred Place Of Death Codes
110	Toelichting	0..1	string
813	c). Euthanasie standpunt	0..1	group
816	MetingNaam voor Euthanasie standpunt	0..1	choice	Options: 1 option Initial Value: Coding = SNOMED CT#340171000146104 "Standpunt ten opzichte van euthanasie (waarneembare entiteit)"
785	Standpunt (UitslagWaarde)	0..1	choice	Value Set: ACP Position Regarding Euthanasia Codes
112	Toelichting	0..1	string
814	d). Keuze orgaandonatie vastgelegd in donorregister?	0..1	group
817	MetingNaam voor Keuze orgaandonatie vastgelegd in donorregister?	0..1	choice	Options: 1 option Initial Value: Coding = SNOMED CT#570801000146104 "Geregistreerd in orgaan donorregister (bevinding)"
789	Keuze orgaandonatie in donorregister (UitslagWaarde)	0..1	choice	Value Set: ACP Yes, No, Unknown Codes
1036	Meetmethode voor Keuze orgaandonatie vastgelegd in donorregister?	0..1	choice	Options: 1 option Initial Value: Coding = SNOMED CT#1156040003 "Self reported (qualifier value)"
598	6. Wat verder nog belangrijk is	0..1	group
818	MetingNaam voor Wat verder nog belangrijk is	0..1	choice	Options: 1 option Initial Value: Coding = SNOMED CT#247751003 "Gevoel van zingeving (waarneembare entiteit)"
383	Wat verder nog belangrijk is (UitslagWaarde)	0..1	string
115	7. Eerder vastgelegde behandelwensen	0..1	group
253	a). Heeft de patiënt eerder behandelafspraken vastgelegd?	0..1	choice	Value Set: ACP Yes, No, Unknown Codes
254	Toelichting	0..1	string
255	b). Staan in eerder vastgelegde behandelafspraken andere wensen dan nu in deze verklaring?	0..1	choice	Enable When: 253 = Yes (qualifier value) (SNOMED CT#373066001) Value Set: ACP Yes, No, Unknown Codes
119	8. Informatie delen	0..1	group
256	a). Heeft u patient geïnformeerd over eigen verantwoordelijkheid om deze behandelafspraken met naasten te bespreken?	0..1	boolean
257	b). Patiënt gaat akkoord met het delen van deze behandelafspraken met andere betrokken hulpverleners	0..1	choice	Options: 2 options
Documentation for this format

Options Sets

Answer options for 399

urn:oid:2.16.840.1.113883.2.4.3.11.60.40.4.22.1#LL ("Vast telefoonnummer")
urn:oid:2.16.840.1.113883.2.4.3.11.60.40.4.22.1#FAX ("Fax")
http://terminology.hl7.org/CodeSystem/v3-AddressUse#MC ("Mobiel telefoonnummer")
http://terminology.hl7.org/CodeSystem/v3-AddressUse#PG ("Pieper")

Answer options for 400

http://terminology.hl7.org/CodeSystem/v3-AddressUse#HP ("Telefoonnummer thuis")
http://terminology.hl7.org/CodeSystem/v3-AddressUse#TMP ("Tijdelijk telefoonnummer")
http://terminology.hl7.org/CodeSystem/v3-AddressUse#WP ("Zakelijk telefoonnummer")

Answer options for 402

http://terminology.hl7.org/CodeSystem/v3-AddressUse#HP ("Privé e-mailadres")
http://terminology.hl7.org/CodeSystem/v3-AddressUse#WP ("Zakelijk e-mailadres")

Answer options for 410

urn:oid:2.16.840.1.113883.2.4.3.11.22.472#24 ("Wettelijke vertegenwoordiger")
urn:oid:2.16.840.1.113883.2.4.3.11.22.472#1 ("Eerste relatie/contactpersoon")
http://snomed.info/sct#310141000146103 ("Schriftelijk gemachtigde")
urn:oid:2.16.840.1.113883.2.4.3.11.22.472#3 ("Curator (juridisch)")
urn:oid:2.16.840.1.113883.2.4.3.11.22.472#15 ("Mentor")
urn:oid:2.16.840.1.113883.2.4.3.11.22.472#9 ("Anders")

Answer options for 51

http://terminology.hl7.org/CodeSystem/v3-RoleCode#DOMPART ("Partner")
http://terminology.hl7.org/CodeSystem/v3-RoleCode#HUSB ("Echtgenoot")
http://terminology.hl7.org/CodeSystem/v3-RoleCode#WIFE ("Echtgenote")
http://terminology.hl7.org/CodeSystem/v3-RoleCode#FTH ("Vader")
http://terminology.hl7.org/CodeSystem/v3-RoleCode#MTH ("Moeder")
http://terminology.hl7.org/CodeSystem/v3-RoleCode#SONC ("Zoon")
http://terminology.hl7.org/CodeSystem/v3-RoleCode#DAUC ("Dochter")
http://terminology.hl7.org/CodeSystem/v3-RoleCode#BRO ("Broer")
http://terminology.hl7.org/CodeSystem/v3-RoleCode#SIS ("Zuster")
http://terminology.hl7.org/CodeSystem/v3-NullFlavor#OTH ("Anders")

Answer options for 404

urn:oid:2.16.840.1.113883.2.4.3.11.60.40.4.22.1#LL ("Vast telefoonnummer")
urn:oid:2.16.840.1.113883.2.4.3.11.60.40.4.22.1#FAX ("Fax")
http://terminology.hl7.org/CodeSystem/v3-AddressUse#MC ("Mobiel telefoonnummer")
http://terminology.hl7.org/CodeSystem/v3-AddressUse#PG ("Pieper")

Answer options for 405

http://terminology.hl7.org/CodeSystem/v3-AddressUse#HP ("Telefoonnummer thuis")
http://terminology.hl7.org/CodeSystem/v3-AddressUse#TMP ("Tijdelijk telefoonnummer")
http://terminology.hl7.org/CodeSystem/v3-AddressUse#WP ("Zakelijk telefoonnummer")

Answer options for 407

http://terminology.hl7.org/CodeSystem/v3-AddressUse#HP ("Privé e-mailadres")
http://terminology.hl7.org/CodeSystem/v3-AddressUse#WP ("Zakelijk e-mailadres")

Answer options for 819

urn:oid:2.16.840.1.113883.2.4.3.11.22.472#1 ("Eerste relatie/contactpersoon")

Answer options for 77

http://terminology.hl7.org/CodeSystem/v3-RoleCode#DOMPART ("Partner")
http://terminology.hl7.org/CodeSystem/v3-RoleCode#HUSB ("Echtgenoot")
http://terminology.hl7.org/CodeSystem/v3-RoleCode#WIFE ("Echtgenote")
http://terminology.hl7.org/CodeSystem/v3-RoleCode#FTH ("Vader")
http://terminology.hl7.org/CodeSystem/v3-RoleCode#MTH ("Moeder")
http://terminology.hl7.org/CodeSystem/v3-RoleCode#SONC ("Zoon")
http://terminology.hl7.org/CodeSystem/v3-RoleCode#DAUC ("Dochter")
http://terminology.hl7.org/CodeSystem/v3-RoleCode#BRO ("Broer")
http://terminology.hl7.org/CodeSystem/v3-RoleCode#SIS ("Zuster")
http://terminology.hl7.org/CodeSystem/v3-NullFlavor#OTH ("Anders")

Answer options for 82

null#Patiënt ("Patiënt")

Answer options for 415

urn:oid:2.16.840.1.113883.2.4.3.11.22.472#3 ("Curator (juridisch)")
urn:oid:2.16.840.1.113883.2.4.3.11.22.472#15 ("Mentor")
http://snomed.info/sct#310141000146103 ("Schriftelijk gemachtigde")
urn:oid:2.16.840.1.113883.2.4.3.11.22.472#9 ("Anders")

Answer options for 80

http://terminology.hl7.org/CodeSystem/v3-RoleCode#DOMPART ("Partner")
http://terminology.hl7.org/CodeSystem/v3-RoleCode#HUSB ("Echtgenoot")
http://terminology.hl7.org/CodeSystem/v3-RoleCode#WIFE ("Echtgenote")
http://terminology.hl7.org/CodeSystem/v3-RoleCode#FTH ("Vader")
http://terminology.hl7.org/CodeSystem/v3-RoleCode#MTH ("Moeder")
http://terminology.hl7.org/CodeSystem/v3-RoleCode#SONC ("Zoon")
http://terminology.hl7.org/CodeSystem/v3-RoleCode#DAUC ("Dochter")
http://terminology.hl7.org/CodeSystem/v3-RoleCode#BRO ("Broer")
http://terminology.hl7.org/CodeSystem/v3-RoleCode#SIS ("Zuster")
http://terminology.hl7.org/CodeSystem/v3-NullFlavor#OTH ("Anders")

Answer options for 790

http://snomed.info/sct#180771000146100 ("Focus van behandeling (waarneembare entiteit)")

Answer options for 791

http://snomed.info/sct#89666000 ("Cardiopulmonale resuscitatie (verrichting)")

Answer options for 587

urn:oid:2.16.840.1.113883.2.4.3.11.60.40.4#JA ("Ja")
urn:oid:2.16.840.1.113883.2.4.3.11.60.40.4#JA_MAAR ("Ja, maar met beperkingen")
urn:oid:2.16.840.1.113883.2.4.3.11.60.40.4#NEE ("Nee")
http://terminology.hl7.org/CodeSystem/v3-NullFlavor#UNK ("Onbekend")

Answer options for 794

http://snomed.info/sct#40617009 ("Kunstmatige beademing (verrichting)")

Answer options for 588

urn:oid:2.16.840.1.113883.2.4.3.11.60.40.4#JA ("Ja")
urn:oid:2.16.840.1.113883.2.4.3.11.60.40.4#JA_MAAR ("Ja, maar met beperkingen")
urn:oid:2.16.840.1.113883.2.4.3.11.60.40.4#NEE ("Nee")
http://terminology.hl7.org/CodeSystem/v3-NullFlavor#UNK ("Onbekend")

Answer options for 795

http://snomed.info/sct#305351004 ("Opname op intensive care (verrichting)")

Answer options for 589

urn:oid:2.16.840.1.113883.2.4.3.11.60.40.4#JA ("Ja")
urn:oid:2.16.840.1.113883.2.4.3.11.60.40.4#JA_MAAR ("Ja, maar met beperkingen")
urn:oid:2.16.840.1.113883.2.4.3.11.60.40.4#NEE ("Nee")
http://terminology.hl7.org/CodeSystem/v3-NullFlavor#UNK ("Onbekend")

Answer options for 799

http://snomed.info/sct#32485007 ("Opname in ziekenhuis (verrichting)")

Answer options for 590

urn:oid:2.16.840.1.113883.2.4.3.11.60.40.4#JA ("Ja")
urn:oid:2.16.840.1.113883.2.4.3.11.60.40.4#JA_MAAR ("Ja, maar met beperkingen")
urn:oid:2.16.840.1.113883.2.4.3.11.60.40.4#NEE ("Nee")
http://terminology.hl7.org/CodeSystem/v3-NullFlavor#UNK ("Onbekend")

Answer options for 801

http://snomed.info/sct#281789004 ("Antibiotische therapie (verrichting)")

Answer options for 591

urn:oid:2.16.840.1.113883.2.4.3.11.60.40.4#JA ("Ja")
urn:oid:2.16.840.1.113883.2.4.3.11.60.40.4#JA_MAAR ("Ja, maar met beperkingen")
urn:oid:2.16.840.1.113883.2.4.3.11.60.40.4#NEE ("Nee")
http://terminology.hl7.org/CodeSystem/v3-NullFlavor#UNK ("Onbekend")

Answer options for 803

http://snomed.info/sct#116762002 ("Toediening van bloedproduct (verrichting)")

Answer options for 592

urn:oid:2.16.840.1.113883.2.4.3.11.60.40.4#JA ("Ja")
urn:oid:2.16.840.1.113883.2.4.3.11.60.40.4#JA_MAAR ("Ja, maar met beperkingen")
urn:oid:2.16.840.1.113883.2.4.3.11.60.40.4#NEE ("Nee")
http://terminology.hl7.org/CodeSystem/v3-NullFlavor#UNK ("Onbekend")

Answer options for 805

http://terminology.hl7.org/CodeSystem/v3-NullFlavor#OTH ("Overige behandelingen")

Answer options for 593

urn:oid:2.16.840.1.113883.2.4.3.11.60.40.4#JA ("Ja")
urn:oid:2.16.840.1.113883.2.4.3.11.60.40.4#NEE ("Nee")
http://terminology.hl7.org/CodeSystem/v3-NullFlavor#UNK ("Onbekend")

Answer options for 809

http://snomed.info/sct#400231000146108 ("uitzetten van cardioverter-defibrillator in laatste levensfase (verrichting)")

Answer options for 595

urn:oid:2.16.840.1.113883.2.4.3.11.60.40.4#JA ("Ja")
http://terminology.hl7.org/CodeSystem/v3-NullFlavor#ASKU ("Nee, nog geen besluit genomen")
http://terminology.hl7.org/CodeSystem/v3-NullFlavor#NASK ("Niet besproken")

Answer options for 811

http://snomed.info/sct#153851000146100 ("Wensen en verwachtingen met betrekking tot uitkomst van behandeling")

Answer options for 1034

http://snomed.info/sct#370819000 ("Vaststellen van persoonlijke waarden en wensen met betrekking tot zorg")

Answer options for 1035

http://snomed.info/sct#395091006 ("Voorkeur voor plaats van overlijden (waarneembare entiteit)")

Answer options for 816

http://snomed.info/sct#340171000146104 ("Standpunt ten opzichte van euthanasie (waarneembare entiteit)")

Answer options for 817

http://snomed.info/sct#570801000146104 ("Geregistreerd in orgaan donorregister (bevinding)")

Answer options for 1036

http://snomed.info/sct#1156040003 ("Self reported (qualifier value)")

Answer options for 818

http://snomed.info/sct#247751003 ("Gevoel van zingeving (waarneembare entiteit)")

Answer options for 257

http://snomed.info/sct#441898007 ("Akkoord")
http://terminology.hl7.org/CodeSystem/v3-NullFlavor#UNK ("Nog onbekend")